WORKERS COMPENSATION APPLICATION - …

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TMDATEPHONEPHONEPRODUCERCOMPANYCOMPANYUN DERWRITERUNDERWRITER(A/C, No, Ext):(A/C, No, Ext):FAX(A/C, No):INTERNET ADDRESS:APPLICANTNAMEMAILINGMAILINGADDRE SSADDRESS(Including(IncludingZIP code)ZIP code)YRS IN BUSYRS IN BUSSICSICCREDITCREDITCODE:CODE:SUB CODE:SUB CODE:ID NUMBER:ID NUMBER:BUREAU NAME:BUREAU NAME:OTHER RATING BUREAU ID OR STATEOTHER RATING BUREAU ID OR STATEAGENCY CUSTOMER IDAGENCY CUSTOMER IDFEDERAL EMPLOYER ID NUMBERFEDERAL EMPLOYER ID NUMBERNCCI ID NUMBERNCCI ID NUMBEREMPLOYER REGISTRATION NUMBEREMPLOYER REGISTRATION NUMBERBILLING PLANBILLING PLANPAYMENT PLANPAYMENT PLANAUDITAUDITSTREET, CITY, COUNTY, STATE, ZIP CODESTREET, CITY, COUNTY, STATE, ZIP CODEPROPOSED EFF DATEPROPOSED EFF DATEPROPOSED EXP DATEPROPOSED EXP DATENORMAL ANNIVERSARY RATING DATENORMAL ANNIVERSARY RATING DATERETRO PLANRETRO PLANPART 1 - WORKERSPART 1 - WORKERSPART 3 - OTHER STATES INSPART 3 - OTHER STATES INS DEDUCTIBLESDEDUCTIBLESAMOUNT/%AMOUNT/% OTHER COVERAGESOTHER COVERAGESPART 2 - EMPLOYER S LIABILITYPART 2 - EMPLOYER S LIABILITYCOMPENSATION (States) COMPENSATION (States)

24. any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? if yes, explain including